Posterior Retroperitoneoscopic Approach Research Articles

Long-term outcome of retroperitoneoscopic partial versus total adrenalectomy in patients with Cushing's syndrome.

We analyze the long-term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution. One-hundred forty-one patients (129 female, 12 males; mean age: 45.7±12.8years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy. Follow-up data could be obtained for 83 patients. Twenty-four (1male, 23 females; mean age 42.3years) underwent PA and 59TA (6 males, 53 females; mean age 44.6years). Mean follow-up time was 107±68months (range: 6-243months). The median duration of postoperative corticosteroid therapy was 9.5months after PA and 11months after TA (p=0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24months (25% vs. 4%; p=0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy. The risk of local recurrence after partial adrenalectomy in CS is low. Cortical-sparing surgery may shorten corticosteroid supplementation therapy after surgery.

A Canadian centre's experience with prone retroperitoneoscopic adrenalectomy.

Minimally invasive adrenalectomy is the standard of care for the surgical management of benign adrenal disease. The transperitoneal laparoscopic approach (TLA) is the most common approach used worldwide; however, many centres have adopted a posterior retroperitoneoscopic approach (PRA), as it is reported to offer several advantages. We describe our experience with PRA. We performed a retrospective review of the charts of patients who underwent minimally invasive adrenalectomy via PRA or TLA performed by a single endocrine surgeon between September 2010 and December 2019 at a tertiary academic centre in British Columbia, Canada. Patient and tumour characteristics, operative times and postoperative outcomes were compared between the 2 groups. During the study period, 58 patients underwent adrenalectomy via PRA, and 41 underwent adrenalectomy via TLA. The median American Society of Anesthesiologists score was higher in the TLA group than the PRA group (3.0 v. 2.6, p = 0.02). Adrenal glands were heavier in the TLA group than the PRA group (mean 63.4 g v. 19.2 g, p < 0.001). The mean anesthesia preparation time was shorter with PRA than with TLA (51.5 min v. 63.7 min, p < 0.001), as was mean operative time (77.9 min v. 118.4 min, p < 0.001) and mean hospital length of stay (2 d v. 4 d, p < 0.001). There was no difference in the complication rate between the 2 groups. Our study shows that PRA offers shorter operative time and length of stay for appropriately selected patients. Thus, it has become the preferred approach at our centre for minimally invasive adrenalectomy.

Prikaz prve laparoskopske adrenalektomije zbog feohromocitoma u pedijatrijskoj populaciji u Republici Srbiji

Pheochromocytoma is a tumor that arises from adrenal medulla and it is characterized by increased secretion of catecholamines. The incidence of pheochromocytoma is 3 to 8 cases per million inhabitants, of which about 10 to 20% of diagnosed pheochromocytomas occurs in the pediatric population, with a higher frequency in boys. In 1.7% of the pediatric population with hypertension, the cause of hypertension is pheochromocytoma. Due to headaches and verified hypertension on twenty-four-hour holter blood pressure monitoring, the 13-year-old female patient underwent ultrasound, followed by scintigraphy and magnetic resonance imaging of the abdomen, which described an oval change above the right kidney about 4.5 cm in diameter suspected of pheochromocytoma. Twenty-four-hour urine cateholamines showed elevated noradrenaline values as much as 45 times higher than the reference range, as well as elevated Dopamine values. After adequate preparation with phenoxybenzamine and bisoprolol for two weeks, a right laparoscopic adrenalectomy was performed at the University Children's Clinic in Tirsova, which is also the first operation of this type in the pediatric population. Intraoperatively, the maximum value of tension was 180/120 mmHg. Pathohistological findings confirmed pheochromocytoma. Although a rare cause of hypertension in the pediatric population, young patients with newly diagnosed hypertension should be examined for possible pheochromocytoma. Laparoscopic adrenalectomy through both the lateral transabdominal and posterior retroperitoneoscopic approach is the gold standard for the treatment of pheochromocytomas in both the adult and pediatric populations.

Feasibility and safety of the posterior retroperitoneoscopic approach in the resection of aortocaval and infrarenal paraganglioma: a single-center experience

The posterior retroperitoneoscopic approach (PRA) has been under attention as a method for resection of paraganglioma (PGL) for the past few years. However, only a few studies have explored the effectiveness and safety of the PRA for aortocaval and infrarenal PGL resection. We designed this retrospective study to investigate the safety and effectiveness of the PRA for aortocaval and infrarenal PGL resection in a single center. We retrospectively reviewed the medical records of patients who underwent PRA for PGL resection at our medical center from January 2006 to March 2021. Eight patients were enrolled, of whom six had aortocaval PGL. We investigated the surgical outcomes of enrolled patients. The locations of the tumors in relation to the renal vein were: suprarenal in two (25.0%) patients, at the renal vein level in three (37.5%) patients, and infrarenal in three (37.5%) patients. The mean operative time of the enrolled patients was 101.5 ± 39.1min. The mean postoperative stay was 3.5 ± 1.5days, and the estimated blood loss was 31.3 ± 51.4ml. There was one minor complication (chyle leakage), and two hypotensive events occurred during the surgery. Focusing on the results of the renal vein level and infrarenal PGL resection, the mean operative time, mean postoperative stay, and estimated blood loss of the patients were 109.2 ± 41.3min, 3.5 ± 1.8days, and 41.7 ± 56.4ml, respectively. The PRA for aortocaval and infrarenal PGL resection is feasible and safe. Additional data analysis and long-term follow-up are needed in the future.

Posterior Retroperitoneoscopic Adrenalectomy: Recommendations to Implement This Approach

IntroductionThe posterior retroperitoneoscopic approach (PRA) is seldom used in our country to perform adrenalectomies, although it offers possible advantages over laparoscopic anterior or lateral access, according to some authors. The aim of this study was to identify those features that determine the most suitable cases to start the implementation of this technique. MethodsA prospective observational study was performed with a 50-patient cohort. All the cases were operated using the PRA. Sex, age, body mass index (BMI), operative time, left or right side, size and anatomopathological characteristics of the lesion, conversion rates, complications and hospital stay were analyzed. Results25 (50%) women and 25 (50%) men underwent surgery, with a median operative time of 80min (45–180). A significantly shorter operative time (P=.002) was observed in women and in adenomas (P=.002). However, no correlation was observed between surgical time and BMI, lesion side or lesion size. There were no conversions. The complication rate was 14%, and most of the complications were grade I on Clavien–Dindo's scale. Median hospital stay was two days. ConclusionsRetroperitoneoscopic adrenalectomy by posterior approach is a safe and reproducible procedure, with very good outcomes. The most suitable cases to implement this technique would be female patients with adrenal adenomas.

Suprarrenalectomía retroperitoneoscópica por vía posterior. Recomendaciones para la implementación de esta técnica

IntroductionThe posterior retroperitoneoscopic approach (PRA) is seldom used in our country to perform adrenalectomies, although it offers possible advantages over laparoscopic anterior or lateral access, according to some authors. The aim of this study was to identify those features that determine the most suitable cases to start the implementation of this technique. MethodsA prospective observational study was performed with a 50 patients cohort. All the cases were operated using the PRA. Sex, age, body mass index (BMI), operative time, left or right side, size and anatomopathological characteristics of the lesion, conversion rates, complications and hospital stay were analyzed. Results25 (50%) women and 25 (50%) men underwent surgery, with a median operative time of 80 minutes (45-180). A significantly shorter operative time (p = 0.002) was observed in women and in adenomas (p = 0.002). However, no correlation was observed between surgical time and BMI, lesion side or lesion size. There were no conversions. The complication rate was 14%, and most of the complications were grade i in Clavien Dindo's Scale. Median hospital stay was two days. ConclusionsRetroperitoneoscopic adrenalectomy by posterior approach is a safe and reproducible procedure, with very good outcomes. The most suitable cases to implement this technique would be female patients with adrenal adenomas.

Risk factors for complications after robotic adrenalectomy: a review

The application of adrenal surgery has been spreading steadily in recent years. With the increased use of robotics in surgery, robotic adrenalectomy (RA), especially for the posterior retroperitoneoscopic approach, has been taken on by many high-volume institutions as a good option over the standard laparoscopic approach (LA). This paper reviews the recent literature from May 2010 up to November 2019 with the aim of analyzing RA complications in order to identify risk factors for complications after RA. We analyzed 7 principal risk factors for complication: body mass index (BMI), age, tumor size, tumor side, pathology, previous surgery, and surgeon experience. In the review, some studies identified tumor size, malignancy type, completion of learning curve and, and less clearly, previous ipsilateral upper mesocolic or retroperitoneal surgery, as risk factors for postoperative complications and failure of robotic surgery. Whether RA is meaningfully superior to the standard minimally invasive approach is still a subject of discussion. RA appears safer by virtue of its reduction in hospital stay, lower blood loss, and equivalent complication rates, and surgeons should prefer adrenalectomy over the LA. Despite these advantages, the operative time and the overall cost of the robotic procedure are higher than the LA. Further high-quality trials, especially those analyzing the specific risk factors for complications in robotic surgery, should be conducted in order to optimize the stratification of patients eligible for robotic surgery.

Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model.

The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach. Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands. In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156). Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.

Retroperitoneal Paraganglioma Resected Through the Posterior Retroperitoneoscopic Approach

Background: Paragangliomas are rare neuroendocrine tumors arising from neural crest cells. Open exploration and resection are the standard surgical management of retroperitoneal paragangliomas. However, at select centers, both laparoscopic transabdominal and posterior retroperitoneoscopic resection of retroperitoneal paragangliomas have been found to be feasible and safe.1–6 The posterior retroperitoneoscopic approach may have shorter operative time, more direct exposure, less pain, and faster patient recovery than both the open and laparoscopic transabdominal approaches. Methods: The aim of this video is to provide detailed instruction of endoscopic paraganglioma resection through the retroperitoneoscopic approach. Results: The diagnosis of paraganglioma is established by biochemical evaluation and preoperative imaging. The surgical approach uses three incisions in the back, using two 5 mm ports and one central 12 mm port. The retroperitoneal space is developed by blunt dissection and enhanced by CO2 insufflation to 25–30 mmHg. The tumor is carefully dissected and surrounding retroperitoneal structures are preserved. In the current case, the retroperitoneoscopic approach avoided a hostile abdomen because of multiple previous intraabdominal procedures, such as cholecystectomy, appendectomy, hysterectomy, and salpingo-oophorectomy. Conclusions: The posterior retroperitoneoscopic resections of retroperitoneal paraganglioma are feasible and safe. In our experience, the operative time is shorter, with reduced postoperative pain and hospital stay versus the open and laparoscopic transabdominal approaches. It is particularly useful in patients with previous abdominal surgery with the potential of significant adhesions. The cosmetic outcome is excellent. T. S. and T. C. declare that there is no conflict of interests regarding the publication of this article. Runtime of video: 8 mins 26 secs

Posterior retroperitoneoscopic adrenal surgery for clinical and subclinical Cushing’s syndrome in patients with bilateral adrenal disease

The treatment of hypercortisolism for patients with bilateral adrenal disease (BAD) is controversial. Bilateral total adrenalectomy results in permanent hypocortisolaemia requiring lifelong steroid replacement. A more conservative surgical approach, with less than bilateral total adrenalectomy (leaving functional adrenal tissue either unilaterally or bilaterally), represents an alternative option; however, long-term outcome or recurrence data are limited. We report our experience with the surgical management of hypercortisolism caused by BAD. Between 2004 and 2016, 42 patients (12 male, 30 female; mean age 58±10years) with clinical or subclinical Cushing's syndrome (CS/sCS) caused by BAD underwent adrenal surgery via the posterior retroperitoneoscopic approach. Adrenal surgery was defined as "adrenalectomy" when total gland excision was performed or "resection" when a partial or subtotal adrenal resection was performed. Clinical, radiological and biochemical parameters were evaluated preoperatively and postoperatively. Seventy adrenal operations performed in total included unilateral resection (n=3), unilateral adrenalectomy (n=15), bilateral resection (n=9), adrenalectomy and contralateral resection (n=14) and bilateral total adrenalectomy (n=3). Median operating time was 47.5min (30-150) with no difference between unilateral and bilateral (synchronous included) procedures (p=0.15). Mortality was zero. Clavien-Dindo grade of postoperative complications was I (n=5) and IV (n=3). All but one patient with CS and 17/31 patients with sCS received postoperative steroid supplementation for a median duration of 20 (1.5-129) months. After median follow-up of 40months (3-129), the remission rate was 92%; 11 patients required ongoing steroid supplementation. There were three biochemical recurrences (two underwent contralateral resection); two patients with new/progressive radiological nodularity are biochemically eucortisolaemic. A significant reduction in BMI (p=0.01) and antihypertensive requirements (p=0.04) was observed postoperatively. A surgical approach which facilitates the conservation of functional adrenal tissue represents a suitable strategy for hypercortisolism caused by BAD. This approach avoids the necessity for lifelong steroid replacement in the majority of cases with low rates of adrenal insufficiency and recurrence.

Posterior retroperitoneoscopic approach to the adrenal arteries.

Differently from transperitoneal adrenalectomy, with the posterior retroperitoneoscopic approach adrenal arteries are dissected first [1, 2]. Knowledge of their position is pivotal as they are covered by peri-adrenal fat [3, 4]. Four posterior retroperitoneoscopic adrenalectomies were selected, in which adrenal arteries are dissected to show their path and how they can be localized among peri-adrenal fat. A video is presented herein, which focuses on surgical anatomy of adrenal arteries when approached during a posterior retroperitoneoscopic adrenalectomy. Details about relative positions between adrenal arteries and adjacent structures are considered and shown during their dissection. The posterior retroperitoneoscopic approach offers a direct view of adrenal arteries and allows for their exposure and safe division in the early steps of adrenalectomy.

Retroperitoneoscopic Left Adrenalectomy in a 2-Year-Old

Abstract Introduction: The traditional approach for adrenalectomy in children has been the transperitoneal technique. In adults, the posterior retroperitoneoscopic (PR) approach has been promoted.1...

Intraperitoneal Accessory Spleen and Adrenal Myelolipoma

Posterior retroperitoneoscopic approach (PRA) has become an established procedure for retroperitoneal lesions. The authors encountered a 30-year-old male patient who had β-thalassemia major and received splenectomy 15 years previously. Bilateral suprarenal tumors were noted on follow-up sonography. Subsequent computed tomography of the abdomen showed a right adrenal tumor and a left intraperitoneal lesion with homogenous enhancement. Successful bilateral PRA was performed, and histology confirmed the diagnosis of right adrenal myelolipoma and an accessory spleen. For the present case who had a large abdominal scar, PRA is technically feasible for treating patients with intraperitoneal and/or retroperitoneal suprarenal lesions while eliminating the necessity of dissection for intra-abdominal adhesions and patient repositioning for bilateral lesions.

Laparoscopic Adrenalectomy: Retroperitoneal Approach

Laparoscopic adrenalectomy has become the gold standard for removal of benign adrenal masses. Despite initial concerns about safety, a long learning curve, and unfamiliarity of anatomy from the posterior approach, the posterior retroperitoneoscopic approach is now the preferred technique at many institutions, and offers several advantages over the transperitoneal approach, including direct access to the adrenal gland, avoiding negotiating scar tissue from previous abdominal operations, and allowing for bilateral surgery without patient repositioning. This review outlines the operative technique, indications and precautions for the posterior retroperitoneoscopic adrenalectomy.

Laparoendoscopic Single-Site Nephropexy with Homemade Single Port

Introduction: Laparoscopic nephropexy is a safe and effective procedure for symptomatic floating kidney. The posterior retroperitoneoscopic approach is thought to be the most promising method for single-access surgery of the floating kidney. Here, we report our preliminary experiences in laparoendoscopic single-site surgery (LESS) retroperitoneal nephropexy with homemade single port for symptomatic floating kidneys. Materials and Methods: LESS retroperitoneal nephropexy was performed with a homemade single port that was created using an Alexis wound retractor as an access platform through a 2-cm incision beneath the tip of 12th rib.1 This video included a brief presentation of a case of a 65-year-old woman who presented with recurrent urinary tract infection and intermittent right flank soreness when activity. She was a slim woman with a body mass index of 21. The flank soreness was usually exacerbated by an upright position and relived by recumbence. Then, supine and erect intravenous pyelography was performed and it revealed downward displacement of two vertebral bodies of right kidney on erect position. The procedure was completed successfully without conversion. The operative time was 110 min. Results and Conclusions: Between May 2009 and July 2010, we had performed LESS nephropexy for four consecutive patients with symptomatic floating kidneys (bilateral in 1 and right in 3). The mean patient age was 44.6±17.7 years and mean body mass index was 21.4 kg/m2. The mean operative time was 121.0±29.7 min. Mean estimated blood loss was minimal, and mean hospital stay was 3.3±0.5 days. Conversion to an open or conventional retroperitoneoscopic approach was not necessary in all cases. There was no major complication. Follow-up intravenous pyelography study 3 months after procedure revealed that the treated kidneys were in the desired position and axis with a standing descend less than one vertebral body in all patients. In conclusion, LESS retroperitoneal nephropexy with homemade single port is a safe and feasible procedure for symptomatic floating kidneys. Further prospective and long-term studies are warranted to provide more solid evidence with regard to perioperative benefits of LESS nephropexy. All authors have declared no conflicts of interest. Runtime of video: 7 mins 1 sec Shih-Dong Chung and Victor Chia-Hsiang Lin contributed equally to this work.

Effect of Morbid Obesity and Tumor Diameter on Feasibility of Posterior Retroperitoneoscopic Adrenalectomy for Cushing’s Syndrome: Reply

We thank Agarwal and coauthor for their comments about our article [1]. Concerning the question about the number of morbidly obese patients, we found that from 170 patients affected by manifest (mCS) or subclinical Cushing’s syndrome (sCS), 51 patients (30%) had a body mass index (BMI) [ 30 (range, 31–62). The majority were affected by mCS (32 cases, 63%). In particular, 26 patients (51%) had a BMI [ 35. As demonstrated, the posterior retroperitoneoscopic approach is feasible and safe even in these patients as only one conversion to open surgery occurred in this series. Technically essential is an increased CO2-pressure (up to 30 mmHg) that allows an adequate creation of the retroperitoneal space. Concerning suspected adrenal malignancies, we do not follow the concept that the laparoscopic transabdominal approach should be preferred over the retroperitoneoscopic access. In contrast, we see a potential advantage of the retroperitoneoscopic route as peritoneal spillage of tumor cells can be avoided. Fourteen tumors (14/170, 8.2%) were at preoperative imaging C 6 (range, 6–10) cm. If predictable, we do not approach adrenocortical cancer minimally invasive. Beside tumor size and imaging features, type of hormone secretion has to be taken into account. Based on these parameters, we were extremely successful; we removed only one adrenocortical cancer in the series of 170 Cushing patients. As demonstrated earlier, large tumor size itself does not represent a contraindication for retroperitoneoscopic adrenalectomy [2, 3]. Today, we do not see the critical size for malignancy in adrenocortical tumors C 6 cm but in those C 8 cm. From this estimation excluded are bilateral macronodular hyperplasias that are almost always benign.

Posterior Retroperitoneoscopic Adrenalectomy for Clinical and Subclinical Cushing’s Syndrome

Because of co-morbidity, adrenalectomy for adrenal Cushing's syndrome may be associated with an increased complication rate and long operating times. In the present study we report our experience with the posterior retroperitoneoscopic adrenalectomy in a large group of patients with clinical or subclinical Cushing's syndrome. Between July 1994 and June 2009, 170 patients (17 males, 153 females age 50 +/- 13 years; range: 12-78 years) affected by Cushing's syndrome underwent operation via posterior retroperitoneoscopic access. Patients were divided into two groups, those with manifest Cushing's syndrome (mCS) [99 patients: 6 male, 93 female; age 45 +/- 13 years] and those with subclinical Cushing's syndrome (sCS) [71 patients: 11 male, 60 female; age: 56 +/- 11 years]. The sCS classification was assumed in cases without typical clinical symptoms but with a pathological dexamethasone suppression test. Partial adrenalectomy was performed in 35 cases (24 in the mCS-group and 11 in the sCS-group). Mortality was zero; major complications did not occur. The incidence of postoperative minor complications was 5.3%. Mean operating time was 58 +/- 36 min (range: 20-230 min) and did not differ between mCS and sCS patients (58 versus 59 min; p = ns). Postoperative oral steroids supplementation (POSS) was administered in 136 patients (99 mCS, 37 sCS). If POSS was started, mean duration of therapy was 12.3 months (mCS) and 10.3 months (sCS) [p = 0.08], respectively. After a mean follow-up of 70.9 +/- 46.5 months the cure rate was 99.4%. The posterior retroperitoneoscopic approach is fast and safe even in patients with Cushing's syndrome. Partial adrenalectomy represents a new option in the treatment of cortisol-producing adenomas.

Endoscopic adrenalectomy: Is there an optimal operative approach? Results of a single-center case-control study

The choice in between the laparoscopic lateral transabdominal (LTA) or the posterior retroperitoneoscopic (PRA) approach for adrenalectomy is usually based on surgeon's preference, rather than on objective arguments. We compared the intraoperative and postoperative outcomes of LTA and PRA to determine whether there is a preferable approach. Thirty-eight consecutive patients successfully underwent PRA for benign adrenal tumors </=6 cm. A case-control study including 38 patients who successfully underwent LTA was performed. Operative time, intraoperative ventilatory parameters (CO(2) production [Vco(2)], whole body oxygen consumption, arterial partial pressure of carbon dioxide [Paco(2)], and arterial partial pressure of oxygen [Pao(2)]), final histology, complications, postoperative stay, analgesic requirement, time to regain normal bowel function, and time to return to work were recorded and compared between the 2 groups. The 2 groups did not differ in terms of operative time, analgesic requirement, time to first flatus, complication rate, duration of postoperative stay, or final histology. Patients in the LTA group showed significantly lower Paco(2), Pao(2), and Vco(2) at the end of the operation. Patients in the PRA group experienced a significantly faster return to work. No procedure can be considered preferable overall. In cases of bilateral adrenalectomy and previous abdominal surgery, PRA may offer some advantages. Surgeon's preference and experience will continue to guide this choice.

Retroperitoneoscopic Adrenalectomy in Conn’s Syndrome Caused by Adrenal Adenomas or Nodular Hyperplasia

In patients with primary hyperaldosteronism, solitary adrenal adenomas are an indication for surgical intervention. In contrast, adrenal hyperplasia is almost exclusively treated by drugs. In a prospective clinical study 183 patients (81 men, 102 women; age 49.6+/-12.8 years) with Conn's syndrome were operated on using the posterior retroperitoneoscopic approach. Tumor size ranged from 0.2 to 5.0 cm (mean 1.5+/-0.8 cm). Final histology described a solitary adenoma in 127 patients and adrenal hyperplasia in 56 patients. Partial adrenalectomies were performed in 47 operations. The perioperative complication rate was 4%, mortality zero. In none of the cases was conversion to open surgery necessary. The mean operating time was 58+/-32 minutes (range 20-230 minutes) and was associated with sex (p<0.001) but not with the extent of resection (partial vs. total, p=0.51) or with tumor size (<or=1.5 vs. >1.5 cm; p=0.43) or tumor site (p=0.77). Median blood loss was 15 ml. Median duration of postoperative hospitalization was 4 days. After a mean follow-up of nearly 5 years, 96% of patients are normokalemic, 30% of patients are cured (normotensive without medication), and 87% showed an improvement of hypertension (normotensive without or with reduced medication). Cure of hypertension depended on the patient's age (p<0.001) and sex (p<0.001), duration of hypertension (p<0.05), and histomorphology (p<0.001). Improvement of hypertension was not associated with any of these factors. Retroperitoneoscopic removal of adrenal glands in patients with Conn's syndrome is a safe, rapidly performed surgical procedure and can thus be considered as first choice option for treatment of both solitary adrenal adenomas and hyperplasia presenting with a clinically predominating nodule.

Posterior retroperitoneoscopic adrenalectomy—results of 560 procedures in 520 patients

The posterior retroperitoneoscopic adrenalectomy is less popular than the laparoscopic transabdominal method. Due to the direct approach to the adrenal glands, however, the posterior retroperitoneal access is easy to use and may offer advantages not available with other endoscopic procedures for adrenalectomy. Between July 1994 and March 2006, we performed 560 adrenalectomies (right side: n = 258; left side: n = 302) by the posterior retroperitoneoscopic approach in 520 patients (200 male, 320 female; age, 10 to 83 years). Of the 520 patients, 21 suffered from Cushing's disease, 499 patients had adrenal tumors (157 Conn's adenomas, 120 pheochromocytomas [13 bilateral], 110 Cushing's adenomas [6 bilateral], and 112 other tumors). Tumor size ranged from 0.5 to 10 cm (mean, 2.9 +/- 1.7 cm). The procedures were performed with the patients in the prone position usually with 3 trocars. Mortality was zero. Conversions to open or laparoscopic lateral surgery were necessary in 9 patients (1.7%). Major complications occurred in 1.3% of patients, minor complications in 14.4%. Mean operating time was 67 +/- 40 min and declined significantly (P < .001) from the early procedures (106 +/- 46 min) to the later operations (40 +/- 15 min). The posterior retroperitoneoscopic adrenalectomy is a safe and fast procedure. In experienced hands, this method represents the ideal approach in adrenal surgery.